Overcoming the Implementation Gap in Multidisciplinary Oncology Care Programs.

Abstract

Cancer care is increasingly complex, involving multiple screening, diagnostic, staging, treatment, and long-term survivorship care options. As knowledge of cancerbiologyandthe technologyofclinical care advance, seemingly monolithic malignancies with limited management options and uniformly poor outcomes are rapidly exploding inmanydifferent directions,with specific pathways of care leading to significant improvement in patient outcomes. These developments, desirable as they are, pose major problems for patients, caregivers, clinicians, health care systems, and the greater society within which all this is happening. Lung cancer is a poster child for the challenges of this rapid evolution in care delivery. Lungcancer iscomplicated.It iscommon and lethal,withoutcomesheavilydependent on the stage of disease, but it is often identified late, when curative-intent therapy is severely limited. Patients are often affected by cumulative ageand tobacco-related comorbidities. In the United States, the sociodemographics of lung cancer are unfavorable, prevailing, as it does, among the relatively poor and uneducated, among racial minorities, and in regions with the least robust health care infrastructure. The disease itself is relatively inaccessible, requiring a range of high-risk, high-cost, high-technologic approaches to diagnosis, staging, and treatment. These management modalities are controlled by a multiplicity of highly trained, highly skilled, relatively scarce professionals who have significantly different skill sets, sources of knowledge and information, practice cultures, and incentives. All lung cancer care begins with an abnormal radiologic study. It then flows through certain specific steps: a diagnostic biopsy, radiologic and invasive staging tests, treatment selection, and ultimately outcome.Treatment increasingly involves varying combinations of surgery, systemic therapy (including chemotherapy), radiation therapy, and palliative care. The initial radiologic test is usually requested by a primary care provider, emergency room physician, or hospitalist. These clinicians, lacking the skill sets to deliver cancer care, have anonward referralmandate to any one of several involved specialists: pulmonologists, thoracic surgeons, interventional radiologists,medical oncologists, andpalliative care specialists. Knowledge of the variation in quality and outcome of lung cancer care across the spectrum of care delivery and the rapidly expandingmultiplicity of options for care has stimulated the almost universal recommendation for care to be delivered in multidisciplinary fashion, in the hope that better coordination will lead to improved outcomes. Obvious as this recommendationseems, there is an equally obvious problem: A quick look across the care delivery landscape reveals precious little evidence of implementation of multidisciplinary care. There is a wide gap between the nearuniversal expert recommendation for multidisciplinary care and the penetration of